Gingerich-Coping with Stress

Running head: PSYCHOLOGICAL TRAUMA AND COPING 1
History of Childhood Psychological Trauma: A Risk Factor for Coping with Anxiety and Stress
Marisa Joy Gingerich
Vanderbilt School of Nursing

PSYCHOLOGICAL TRAUMA AND COPING 2
History of Childhood Psychological Trauma: A Risk Factor for Coping with Anxiety and Stress
PICO
Persons who have not experienced a traumatic event will respond to stressful situations
differently from those who have experienced traumatic events (John & Gross, 2004). According
to Finkelhor, Turner, Omrod, Hamby, and Kracke (2009), when they were younger,
approximately 2/3 of people have been affected by traumatic experiences. Therefore, the
purpose of this paper is to answer the following question: in patients under twenty-five years old,
how does experiencing psychological trauma compared to experiencing no psychological trauma
influence how the patients cope with anxiety in stressful situations? Several concepts related to
psychological trauma are “Emotional trauma”, “post-traumatic stress disorder” (PTSD), and
“traumatic stressors” (Gold et al., 2010; Kendall-Tackett, 2009; National Panel for Psychiatric-
Mental Health NP Competencies (US), 2003; Sheppard, 2016). The opposing concept is a
“emotion regulation and psychological health” (Department of Psychology, University of
California, Berkeley, 2016). Coping is another major concept that relates to how a person
handles a situation; whereas, psychological adaptation would refer more to the likelihood of a
person adjusting to the current circumstances (U.S. National Library of Medicine, 2016).
Finally, PTSD is an overarching theme for psychological trauma (PubMed.gov, 2016, U.S.
National Library of Medicine, 2016).
Significance to Society
Cost. Furthermore, the cost to society is staggering. Child sexual abuse, bullying in
school, loss of a loved one, living in a warzone, emotional abuse, and other traumatic stressors
can cause damage and anxiety in children that affect the way they respond to new stressors that
cause anxiety (Gill-Appiott, & Murphy, 2015; Kvarme, Monsen, & Eboh, 2014). Anxiety cost

the US government over 40 billion dollars in the 1990s according to the Centers for Disease
Control and Protection (2015).
Burden. Psychological trauma is best explained as an after-effect of having a serious
event that shocks or harms one either emotionally or physically (Giller, 1999). One of the main
ways that the effects are seen is through a psychological disorder called post-traumatic stress
disorder (PTSD) according to the US Department of Veterans Affairs, PTSD: National Center
for PTSD, (2015). Also, included in PTSD is anxiety that is diagnosed only after a traumatic
occurrence in a person’s life (Giller, 1999). Some limiting characteristics for the concept of
psychological trauma include anxiety, coping with stressful situations, and post-traumatic stress
disorder (Gill-Appiott et al., 2015; Giller, 1999). Anxiety is a disorder that can last a lifetime.
(Kendall-Tackett, 2009; US Department of Health and Human Services, National Institute of
Mental Health (HHS), n.d.a; HHS, n.d.b).
Possible changes. The impact on society of the answer to this PICO question would be
in the way an informed public interprets in gracious way interactions with people who have
experienced psychological trauma.
Significance for APRNs and Consumers
APRN role, clinical expertise, PICO question and patient care. Health care providers
see many of the patients for routine health visits or for anxiety, through simple screening tools
patients could be treated for major anxiety issues. Giller (1999) advocated for health care
professionals to be trained and made aware of how to treat patients that come into the office.
Family nurse practitioners (FNPs) will care for patients that face these PTSD related situations
on a daily basis. Learning how to help these patients understand how past psychological trauma
affects their responses to stressful situations can help FNPs improve patients understanding of

themselves and give them tools to cope with new stressors that can cause anxiety (Gill-Appiott et
al., 2015; Giller,1999).
Patient costs-direct and indirect. In the United States in the 1990s, more than half of
children experienced anxiety of any kind and a 5 % of children in the same time period had some
form of PTSD that lasted throughout their life according to HHS (n.d.a). Patients who
experienced psychological trauma often experience difficulty with emotionally adjusting to new
stressful situations without reacting with anxiety (Gill-Appiott et al., 2015). Many patients do
not realize that they are not alone and that they can have help.
Patient preferences. Family nurse practitioners (FNP) are likely to meet persons
experiencing any one of these traumatic experiences but have not received enough training to
differentiate between them. However, they can recognize and treat psychological trauma until
the patient is able to afford or an opening becomes available for them to see a psychiatrist (Gold
et al., 2010; Kendall-Tackett, 2009; Sheppard, 2016; National Panel for Psychiatric-Mental
Health NP Competencies (US), 2003).
Appraising the Research Evidence
After reviewing the body of knowledge surrounding the relationship between
psychological trauma and coping with stress-related anxiety, seven research articles were chosen
for this synthesis paper.
Key Outcome Variables
Several key outcome variables stand out in the seven articles: insecure attachment versus
secure attachment, attachment anxiety versus attachment avoidance, and adult attachment
anxiety versus adult attachment avoidance, early childhood trauma versus adult trauma, PTSD,
and cyberbullying (Kvarme et al., 2014; Busuito, Huth-Bocks, & Puro, 2014). One study used

the following variables: war trauma and behavioral and emotional disorders (Khamis, 2015).
Two studies used the following variables: emotion-focused coping versus problem-focused
coping and neuroticism (Khamis, 2015; Ogle, Rubin, & Siegler, 2015). Ogle et al. (2015) also
researched event centrality. One study covered the following variables: forgivingness, mental
health, physical health, traumatic events, and “life-time stress exposure” (Toussaint, Shields,
Dorn, & Slavich, 2016). Other key variables were overall number of trauma experiences related
to trauma care-seeking behavior in children and adolescents (Briggs et al., 2013). Other
variables researched by another study focused on acute stress disorder and PTSD (Gill-Appiott &
Murphy, 2015).
Theoretical/Conceptual Frameworks
Explicit. A few theories formed the foundation for the research for these studies. Some
theories were explicitly stated. The adult romantic attachment theory by Bartholome and
Horowitz (Busuito et al., 2014) states that adult attachment can be secure or insecure where
persons either use attachment avoidance or attachment anxiety in close relationships depending
on how those persons view themselves and other people whether positively or negatively.
Another theory is acute stress disorder theory (for stress that lasts less than a month) and
posttraumatic stress disorder theory (for stress that is longer than a month; Gill-Appiott et al.,
2015). Attachment theory by Bowlby (Ogle et al., 2015) states that babies make bonds at a
young age with their guardians that have an impact on how they bond with and sustain rapport
with significant others in adulthood. The coping theory by Folkman and Lazarus (1997) is
composed of problem-focused and emotion-focused coping. Problem-focused coping focuses on
solving problems often where the persons only focus on the next thing to do. Emotion-focused
coping can become an endless cycle of enduring pain and trauma with no hope, unless something

comes in and distracts the person from the problem in a good way (Folkman, 1997; Khamis,
2015; Toussaint et al., 2016). Finally, the life-course stress theory by Graham and Lupien is
where persons experience stressors that may be different kinds of trauma or other stressors the
amount of which could negatively impact their mental and physical health throughout their
lifespan (Toussaint et al., 2016).
Implicit. One implicit theory was the trauma-informed care theory (Briggs et al., 2013)
where caregivers who are responsible for caring for victims of trauma need to be aware of
resources available to them and to refer the victims to the appropriate services. The “solution-
focused approach” is another implicit theory that is very similar to the problem-focused coping
skill except that a counselor or other practitioner works with victims of trauma to come up with a
way to make positive changes to cope with the present circumstances and recover from past
traumatic experiences (Kvarme et al., 2014). One final implicit theory is the forgivingness
theory where persons release negative feelings towards those who have traumatized them and
release the need for restitution for the wrongs done to them (Toussaint et al., 2016).
ResearchDesigns
The seven studies were formed using non-experimental, qualitative, or mixed research
designs, which were appropriate designs to use to demonstrate the relationship between
psychological trauma and coping with anxiety although a qualitative design would be the most
appropriate design. Briggs et al. (2013) chose to use a non-experimental retrospective approach
to discover if trauma (including the number experienced) affects how often children use their
facilities and what types of amenities the children use. Busuito et al. (2014) chose a mixed
design employing non-experimental, descriptive, and longitudinal (first wave) along with a
qualitative, grounded theory approach to discover if there is a relationship between trauma and

adult romantic attachment anxiety or adult romantic attachment avoidance in third-trimester,
pregnant women due to the stress level they were experiencing. Gill-Appiott et al. (2015) used a
non-experimental, correlational, cross-sectional, descriptive approach to discover if different
types of trauma experienced by children can predict a risk for PTSD in either the children or
their parents or both. Khamis (2015) chose a non-experimental, cross-sectional correlational
design to explore whether war trauma has a significant psychological impact on children who
experience it. Kvarme et al. (2014) chose a case study to show the effect of trauma specifically,
cyberbullying, on a young girl. Ogle et al. (2015) explored how insecure attachment affects
diagnosis of PTSD including both attachment avoidance and attachment anxiety, in older
adulthood is due to trauma experienced as a child versus as an adult using the non-experimental,
developmental, longitudinal (13th wave) design. Finally, Toussaint et al. (2016) chose to use a
non-experimental, cross-sectional, correlational study to discover if demonstrating forgivingness
after trauma has an effect on mental and physical well being. Each of the authors chose a design
that allowed them to discover more about how trauma affects individuals and explored different
ways of coping with the anxiety or PTSD.
Samples
Although the sample sizes varied from one person in a case study (convenience sample;
Kvarme et al., 2014) to over 11,000 (Briggs et al., 2013) the majority ranged from 100 to 200
people (Busuito et al., 2014; Gill-Appiott et al., 2015; Khamis, 2015). The most diverse samples
that included low socioeconomic status, ethnic minorities, and an even sample of men and
women in the studies were utilized by Briggs et al. (2013) who used purposive sampling and
Busuito et al. (2014) who used purposeful sampling. Briggs et al. (2013) noted that over three-
fourths of their 0-18 year-olds sample had been exposed to more than one trauma. Busuito et al.

(2014) noted that of the 120 pregnant women in the study 43% had experienced child abuse and
78% intimate partner violence. Inclusion criteria were third trimester pregnancy and speaking
English. Gill-Appiott et al. (2015) used convenience sampling and trauma-exposed children
(68% were male), but did not consider ethnicity or socioeconomic status in their study. Ogle et
al. (2015) used convenience sampling and, thus, had a very large high socioeconomic status,
mostly male, and 99% white sample that had at least one trauma exposure. Those with missing
data were excluded. Toussaint et al. (2016) also used convenience sampling and did not
delineate the ethnicity or socioeconomic status of the sample. Although the sample was
primarily composed of young adults, the sample was evenly distributed between men and women
at 46% to 54% respectively. Furthermore, the authors did not state the number of people who
were exposed to trauma. Although Khamis (2015) used the Gaza strip census to randomly select
families who were allowed to choose if they wanted to complete the interview questionnaires.
One child in each participating family was randomly selected to create an even ratio of girls to
boys to complete the survey. Although the samples are very diverse, similarities exist as the
people in the samples have experienced trauma or some form of life stressor.
Data Collection Measures
For data collection in the different studies, the authors chose to use self-report
questionnaires delivered either through interviews (Briggs et al., 2013; Busuito et al., 2014; Gill-
Appiott et al., 2015; Khamis, 2015; Kvarme et al., 2014), through a mail-out (Ogle et al., 2015),
or through a computer (Briggs et al., 2013; Toussaint et al., 2016). The case study declared
clearly how the data was collected and recorded using the Omaha system. The reliability and
validity remains to be determined after it is applied to a larger sample size (Kvarme et al., 2014).
All the rest of the studies’ authors clearly defined their data collection methods and the reliability

and validity of their data (Briggs et al., 2013; Busuito et al., 2014; Gill-Appiott et al., 2015;
Khamis, 2015; Kvarme et al., 2014; Ogle et al., 2015; Toussaint et al., 2016).
Analysis of the Research Evidence
Strengths
Research on how trauma affects coping with anxiety under stress is wide and varied. The
authors of the studies included in this literature review used a variety of well-researched
questionnaires to gather their data and compared their data to the information provided by the
psychometric research on those questionnaires or provided good rationales for the use of their
collection methods (Briggs et al., 2013; Busuito et al., 2014; Gill-Appiott et al., 2015; Khamis,
2015; Kvarme et al., 2014; Ogle et al., 2015; Toussaint et al., 2016). Other than Kvarme et al.
(2014) all the authors chose to use designs that provided the highest level of evidence ethically
available for this body of knowledge.
Limitations/Weaknesses
One limitation to the research is that it would be unethical to do a randomized control
trial to control for psychological trauma exposure. Therefore, the findings presented cannot be
generalized to the entire population. Another limitation is that most of the studies were small
single non-experimental studies that used self-report or observation styles to gather data, which
weakens the suggestions that the researchers of the studies made (Busuito et al., 2014; Gill-
Appiott et al., 2015; Khamis, 2015; Toussaint et al., 2016). Ogle et al. (2015) do not state how
they contacted their sample and who participated from the entire group contacted. Kvarme et al.
(2014) chose to present a single case study that is the weakest level of evidence (LoBiondo-
Wood & Haber, 2013).
Gaps

The literature review of the studies showed a need to research effective ways to treat
youth who have experienced trauma (Briggs et al., 2013) and adults. One study discussed adding
treatment that includes therapy on how to form secure attachments with significant others
(Busuito et al., 2014). More research should be done on the correlation between how
experiencing trauma as a child can be a risk factor for developing PTSD later in life (Busuito et
al., 2014; Gill-Appiott et al., 2015; Khamis, 2015; Ogle et al., 2015).
Synthesis of the Body of Knowledge
Key findings
A few key findings show a strong relationship between trauma and PTSD (Busuito et al.,
2014; Gill-Appiott et al., 2015; Khamis, 2015 & Ogle et al., 2015), especially where the persons
also experienced insecure attachment such as attachment avoidance (Busuito et al., 2014). Ogle
et al. (2015) also found that the trauma experienced at a young age as compared to trauma
experienced as an adult is more likely to result in PTSD and insecure attachment (attachment
anxiety) as an adult. Another finding of note is that, in those persons that have experienced
trauma, secure attachment may act as a moderator for the persons who would normally develop
PTSD (Busuito et al., 2014 & Ogle et al., 2015). Briggs et al. (2013) showed that 31% of the
children in their system had experienced greater than or equal to five traumatic experiences, 65%
used social services, and 35% used school services offered to them. However, many of the
centers were not prepared to provide the services these children affected by trauma.
Furthermore, problem-focused coping strategies appeared to provide stability for those
recovering from war trauma showing significantly less PTSD or other mental health problems
(Khamis, 2015). Although an emotion-focused coping skill, forgivingness has been shown to
increase a person’s use of problem-focused coping skills. Forgivingness may also be a

moderator in increasing mental health states and decreasing life-stressors for those who practice
forgivingness. However, there was no conclusive evidence on the impact of forgivingness on
physical health that had been damaged by life stressors (Toussaint et al., 2016). For people who
have difficulty coping with trauma and anxiety on a daily basis, the OMAHA system and the
“Solution Focused Approach” or problem-focused coping skill demonstrated in the case study by
Kvarme et al., (2014) gives counselors a chart with questions to ask and a model to help the
clients determine emotional triggers and to come up with solutions to the problems.
Strength and Level of Evidence
According to LoBiondo-Wood et al. (2013, p.15) there are seven levels of evidence.
Since none of the studies are experimental or even quasi experimental, the strength of evidence
can give proposals but cannot give strong recommendations regarding their findings. Five
studies are level IVs on the “Levels of Evidence” pyramid because they are non-experimental
(Briggs et al., 2013; Gill-Appiott et al., 2015; Khamis, 2015; Ogle et al., 2015; Toussaint et al.,
2016). The case study is a level VI and is not very strong and can only be used to support
research from other studies or give insight on where more research is needed (LoBiondo-Wood
& Haber, 2013, p. 15; Kvarme et al., 2014). Finally, Busuito et al. (2014) employed a mixed
design that gives the study a dual level of evidence at IV due to its non-experimental design and
VI due to the nature of the interview style to gain information on the participants’ personal
experiences. For the nature of the research for this body of knowledge a majority of level IV
evidence studies is satisfactory.
Summary of Body of Evidence
Psychological trauma affects people in every sector of life from the poor to the rich,
across ethnicities, continents, and both the young and the old. The earlier the trauma occurs the

larger the impact on attachment that may also result in more extreme PTSD in adulthood
(Busuito et al., 2014 & Ogle et al., 2015). Therefore, learning to cope with anxiety under stress
becomes very important in order if the persons have experienced trauma and demonstrate
insecure attachment. Several coping skills were proposed in the literature review: meeting with a
counselor who uses a “solution-focused approach” and the OMAHA system (Kvarme et al.,
2014), forgivingness (Toussaint et al., 2016), and learning problem-focused coping skills
(Khamis, 2015 & Toussaint et al., 2016). Additionally, early identification of predictors of
PTSD can be diagnosed using the STEPP tool used in the study by Gill-Appiott et al. (2015).
Applications
APRN practice
In brief, while caring for patients, APRNs need to assess their patients for a past history
of child abuse and ask how patients relate to their significant others as insecure attachment and
child abuse together predispose persons for developing PTSD (Busuito et al., 2014; Ogle et al.,
2015). One tool that may be used by APRNs in the future is the STEPP tool (after more non-
experimental clinical trials), which assesses patients for a risk of developing PTSD (Gill-Appiott
et al., 2015). Performing early interventions in teaching patients forgivingness (Toussaint et al.,
2016) and problem-focused coping skills can reduce the likelihood of the patients developing
PTSD (Khamis, 2015). In order to spread awareness of the issue, APRNs can discuss in local
nurse practitioner meetings the issue of how childhood psychological trauma impacts a patient
and predisposes them to suffer from PTSD. Another way is for APRNs to make appearances at
local organizations and the city of commerce-even lobbying at the state and national senates-to
educate the public on the issue.
Future research

Two research questions that the research raise are how does forgivingness promote
problem-focused coping behavior (Toussaint et al., 2016) and how does problem-focused coping
behavior act as a protective mechanism against PTSD development (Khamis, 2015). Further
studies need to use a non-experimental, longitudinal design, using larger sample sizes with more
ethnically, culturally, and socioeconomically diverse sample size using purposive sampling
selection. Research regarding how trauma affects people cannot be done quasi-experimentally or
experimentally, as it would be unethical to purposely expose people to trauma. Psychology
nurse practitioners, licensed professional counselors, primary care providers, and social workers
would be the minimum amount of people needed to begin the research.
Summary
Nurse practitioners can have a major impact in nurturing their patients’ return to a healthy
state of mind after traumatic events. The APRN can do this by being aware the types of
attachments their patients may be making with their significant others and of how that ties in
with child abuse to be a risk factor for PTSD development (Ogle et al., 2015). By screening
using the STEPP tool and, in the future, the OMAHA system, the APRN may be able to identify
patients at risk for developing PTSD and refer them to counseling or a psychiatrist (Busuito et
al., 2014; Kvarme et al., 2014). Also, the APRN can mention to patients the benefits of
forgivingness on stabilizing mental health. As consumers of health care, patients who have
experienced psychological trauma have the right to feel cared for and the right to be understood.
Patients need primary care providers (PCPs) who will be able to understand how they receive
information and interpret the world around them.

References
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